The Anticipatory Care Paradox and Overdiagnosis: Subjective Pragmaticism trumps Objective Empiricism

An example:

Take the sentence:

“Early diagnosis of cancer by population based screening prevents cancer deaths and is a good thing.”

This summarises the concept underlying, say, the UK national breast cancer screening programme (UKNHSBCSP).

It is an example of the concept of anticipatory care in general where :

“Predictive risk measurement and diagnosis by population based anticipatory care programmes prevents premature death and is a good thing.”

What is at stake here is “a good thing”.

The question is: “What determines whether the concept should be marketed, commissioned or translated into state policy, as so-called evidence based healthcare, as, that is, a good thing ?”

For pragmatism (P) ‘a good thing’ is a practical thing, where the term practical, as used here, specifically means that the specific form of anticipatory care achieves the active intent of the programme, here defined as preventing specific forms of (premature) death.

By contrast, for Logical Empiricism (LE), the question posed of a good thing depends upon an evaluation of all of the possible conceivable and observable effects of the programme.

So, for example, LE would take into account and value as meaningful, as many empirical observations of harms as possible, such as the impacts on health of for example, mastectomy as such, of side effects and complications, and of longer term but still conceivable, observable, sequelae (such as radiation induced cancer and heart disease).

For LE the so-called observation-sentences (for example, “mastectomy can lead to wound infections and chronic pain”) that attest to the predicate “a good thing” must refer to observable empirical outcomes that make sense, have empirical meaning, and are therefore sensuous, imaginable or conceivable at an individual level.

Therefore, overdiagnosis (OD) is not a meaningful outcome for LE because, most simply put, it is not sensually experienced.

This is a dilemma for scientists who ‘feel’ OD is important but are unable, under the precepts of LE, the basis of Evidence Based Healthcare (EBHC), to make it count as value-able in the inquiry into, say, breast cancer screening.

As an aside, the term premature functions here as an imperative term for the subject. It signifies the subject for another signifier thus: “You not only can but should, even must, try to prevent your premature death, because your proper mature death lies further in the future, some time, not defineable.”

LE accepts the existence and importance of causes and mechanisms of ill health production, such as, say, radiation inducing cancers, because these help to identify possible conceivable, observable, outcomes, which will therefore influence methodology and study design. For P, these causes and mechanisms do not exist, or are meaningless, because the focus is on the relevance of outcomes to the active intent of the programme of anticipatory care and not the wider evaluation of what might be, or attest to, a “good thing”.

In the evaluation of the UKNHSBCSP we can see the workings of a subjective pragmaticist empiricism, that trumps LE in general.

So, that a statement by a cancer expert in 2012 , by Prof. David Cameron, who was on the UK’s independent review panel for the UKNHSBCSP:

“I personally would prefer to avoid a breast cancer death … and the risk that I might have a cancer over diagnosed and therefore treated is one I would be prepared to take”

effectively privileges the active intent of the programme at the expense of other harms that may, if counted and valued as harm as such, negate the conclusion that screening is a “good thing”.

This privileging of the active intent of an intervention devalues harms as such and leads to ever expanding, intensifying forms of anticipatory care and overdiagnosis. It also privileges the intent, scientific interests and healthcare goals of particular clinical specialisms. Cancer specialists tend to be pragmaticist, and therefore interventionist, with respect to their own cancer research and interventions.

Overdiagnosis is an anomaly, meaningless for P, and a contradiction for LE.For P it is meaningless because it is not relevant to the active intent of anticipatory care. For LE, it may be conceivable and measurable at a population level but it is not observable. To be observable is to be experienceable at an individual level. And although it is (indirectly) deduced and measured by LE as a logical (positivist) population outcome – OD is not empirical, it is purely positivist. Thus, OD is, in theory, finite and determinate, and measureable, but it is not imaginable, experienceable, or, literally, sensible.

LE is an ally for social democracy under capitalism because it attempts to value all possible conceivable and observable outcomes that attest to a good thing. It is more likely to objectively strike a more equal, just balance between the harms and benefits of forms of healthcare.

Conversely, P is an ally of neoliberalism under capitalism. Capitalism needs competition and innovation and monetised growth to survive. Because P ignores harms not relevant to the active intent it privileges intervention, and therefore promotes neoliberalism’s necessary endless innovation and the marketisation of ‘new’ products as a good thing.

Therefore, LE has more potential to limit harms due to anticipatory care whereas P continually intensifies harms due to anticipatory care.

The social democratic LE scientists would like to value OD, as harm as such in determining a good thing, for the sake of collective justice, but are unable to make it count as value-able for themselves, and even less so for the neoliberal pragmaticists who are only swayed by active intent, that is, for example, by saving lives from breast cancer deaths.

In the anticipatory mode of care overdiagnosis is an inevitability, but, at the same time it is personally unimaginable, and so compelling citizens to decide whether to comply with screening invitations, as if this is a ‘fully informed’ and ‘fair’process, is anti-democratic.

The cause of this situation is the belief that it is possible to scientifically define the precise biological boundary between normal and pathological forms of life in order to predict future disease. But, because life itself functions alongside and through error: environmental contingencies, constant mutations and non-linear responses – it is inherently unpredictable. To claim, for example, that a screen diagnosed cancer is always ‘real cancer’ when only 1 in 3 of them would have caused harm in the future, is to deny life’s mystery, this unpredictability.

Because of the unpredictability pre-emptive attempts to treat on the basis of anticipation will always over treat, and this will always result in non-empirical, non-sensible, unimaginable, non experienced, overdiagnosis at an individual level. And therefore anticipatory modes of care will always be unjust and anti democratic. It will make the citizen increasingly vulnerable to being positioned as limitless clinical labour for a neoliberalised monetised market, warranted not by a social democratic objective logical empiricism but by an interest driven neoliberal subjective pragmaticist empiricism.

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